What Should I Do if My Doctor Says I Need a Drug That’s Not Covered?
If your medication isn’t covered, ask your doctor if your insurer’s formulary has a viable alternative. If not, they can submit a formulary exception request on your behalf.
“Get your doctor to say in writing why this is the most appropriate medication and why a substitute wouldn’t be appropriate,” says Giusti.
An effective letter adheres to a few key points. “The most important thing is language,” says Kiara DeWitt, RN, a former pediatric neurology nurse in Colleyville, Texas, whose patient advocacy efforts include helping patients decode insurance denials and navigate billing misfires. “Insurance companies respond to very specific phrasing.”
“If your provider says, ‘patient needs X,’ that is a maybe. If they say, ‘documented failure on formulary alternative,’ the odds go way up,” she says. “If they add ‘evidence of escalation protocol failure’ or ‘risk of irreversible condition progression,’ that kicks it up again. These details matter. Get clinical. Get exact. Avoid emotion. Speak their language.” Medicare requires the prescriber’s supporting statement to explain the medical reason for an exception.
Some insurance plans allow formulary exceptions to be submitted online.
Check your health plan’s website to see if you can file electronically. If you’re denied approval, the Patient Advocate Foundation advises calling your health plan about the denial. Every plan is required to have an appeals process, so ask what the timeline is for submission. You can file the appeal on your own, ask your doctor for assistance, or seek out a patient advocate to help.
